Thank You

1-833-24RENAL info@khccares.com

Thank you for your appointment request with the Kidney and Hypertension Center.
We will contact you as soon as possible.

For immediate assistance, please feel free to call us at:
1-833-24RENAL / 1-833-247-3625

"*" indicates required fields

I am a*

Provider Referring a Patient

New Patient Requesting an Appointment

NOTE: If you are a returning patient, please call 1-833-24RENAL to schedule.

First Name*

Last Name*

DOB*

Phone*

Zip Code*

Preferred Provider

Preferred Location

Reason For Visit

Add Comments

Referring Provider's Name

Referring Health System

Referring Provider's Phone

Referring Provider Email